Medicaid Managed Care Expansion

Information is available on the Texas Health and Human Services Commission (HHSC) Medicaid Managed Care Initiatives website. Providers may also access this website from the Texas Department of Aging and Disability Services (DADS) Resources for Service Providers website. From this page, click on the navigation button for the desired program, select "Managed Care Expansion Resources" from the menu on the left of the screen, then select "HHSC Star+Plus Medicaid Managed Care Initiatives Website."

The effective date for Star+Plus Medicaid acute care for people with IDD is Sept. 1, 2014. The effective date for nursing facility residents is March 1, 2015.

Acute care services include both routine and emergency medical services including:

• doctor visits,
• hospitalization and hospital-related services,
• prescription medications,
• acute-covered adaptive aids, and
• medical equipment.

Only acute care services for people who live in an intermediate care facility (ICF/IID) or who receive services from the Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS), or Texas Home Living (TxHmL) programs will transition to Star+Plus on Sept. 1, 2014. DADS has contracted with LTSS providers to continue providing services through the individual’s IDD program.

HHSC has developed multiple letters for each group of people affected by the managed care transition. Letters were mailed to all Star+Plus candidates in early May and included information about:

• The expansion
• When the person could expect to receive an enrollment packet
• MCOs serving their area
• How to notify HHSC of their MCO selection
• What happens if they don’t choose an MCO by the deadline

The letters also included URLs (web addresses) for each MCO. The letters also encouraged people/family members to review the online material, including the provider directory.

MAXIMUS, the enrollment broker, mailed enrollment packets in June. In July, MAXIMUS sent a reminder letter to mandatory candidates who had not notified HHSC of their MCO selection. Mandatory candidates who do not notify HHSC of their MCO selection by Aug. 15, 2014, will be assigned to an MCO that serves the area in which they live. After someone is is enrolled with an MCO, the MCO will notify the person of their MCO service coordinator’s (SC’s) name and contact information. DADS providers are encouraged to ask the people they serve for this information.

Beginning Sept. 1, 2014, Star+Plus enrollment for acute care services is mandatory for people age 21 and older who

• have IDD,
• receive Medicaid, but not Medicare Part B, and
• live in an ICF/IID or receive waiver services through CLASS, DBMD, HCS or TxHmL.

Star+Plus enrollment for acute care services is voluntary for children and young adults (age 20 and younger) who

• have IDD,
• receive Medicaid, but not Medicare Part B,
• live in an ICF/IID or receive waiver services through CLASS, DBMD, HCS or TxHmL.

HHSC will continue to issue a "Your Texas Benefits" card to every Medicaid recipient. This card is used to verify the person’s Medicaid eligibility and to cover Medicaid services not covered by managed care.

People who live in an ICF/IID or who receive CLASS, DBMD, HCS or TxHmL services &mdash and who enroll in Star+Plus for acute care on Sept. 1, 2014 &mdash will be issued an MCO identification. The MCO identification card will be used for acute care services covered through managed care.

The redetermination process is how HHSC verifies that a person continues to remain eligible for Medicaid benefits.

A person, or his or her authorized representative, either can call 2-1-1 to ask about their annual Medicaid redetermination date or they can visit the Your Texas Benefits website to get the information. HHSC mails a redetermination packet at least 60 days before the person’s annual redetermination date. When someone receives an annual redetermination packet, the provider may record the redetermination date so that they can estimate the redetermination date for the following years.

People who receive SSI benefits from the Social Security Administration (SSA) are categorically eligible for SSI Medicaid and, therefore, do not have to recertify with HHSC each year. To maintain SSI benefits, the SSA may require information from the person related to their SSI benefits. But as long as the person receives SSI, they are eligible for SSI Medicaid.

The person or their representative payee may call the SSA. Neither DADS nor HHSC plays a role in determining SSI eligibility.

People who have IDD who receive Medicare Part B and live in an ICF/IID or receive CLASS, DBMD, HCS or TxHmL services are excluded from enrolling in Star+Plus for acute care.

Medicare Part D alone does not exclude an individual from enrolling into Star+Plus acute care services on Sept. 1, 2014.

A valid LOC (ID/RC) and IPC are used to identify people who live in an ICF/IID or who are enrolled in CLASS, DBMD, HCS or TxHmL. If a person’s ID/RC or IPC is expired, the MCO won’t know that the person is still enrolled in an ICF/IID or CLASS, DBMD, HCS, or TxHmL and may enroll him or her in Star+Plus for LTSS. In addition, a person who is eligible for Medicaid only due to their waiver enrollment status may become ineligible for Medicaid. The MCO may disenroll the person from Star+Plus acute care services.

The LOC (ID/RC) and IPC are used to identify people who live in an ICF/IID or who are enrolled in CLASS, DBMD, HCS or TxHmL. At least once a month, HHSC provides the MCOs a "type of assistance" code identifying these people.

It is vital that providers make ID/RC and IPC renewal submissions to DADS for everyone in their program as early as possible to avoid affecting Star+Plus acute care eligibility. Although the Star+Plus managed care expansion for acute care services is voluntary for children and people 20 and younger who receive SSI benefits (and excludes people who receive both Medicaid and Medicare Part B), if a person’s LOC or IPC authorization for the DADS IDD program lapses, their Medicaid "type of assistance" code automatically is changed in HHSC’s Medicaid TIERS system and the managed care enrollment broker may automatically enroll them in Star+Plus for LTSS, causing the person to lose eligibility for their DADS program.

An ID/RC may be submitted for various purposes:

• A "PC 2" ID/RC is submitted to DADS during the pre-enrollment process to establish an initial LOC (and for some programs to also establish an initial level of need [LON]).
• A "PC 3" ID/RC is submitted to DADS annually to renew a person’s ID/R.
• A "PC 4" ID/RC, which is used in HCS only, is submitted to DADS to request an change in an individual's LON assignment.
• A "PC E" ID/RC is used to cover a lapse in ID/RC authorization dates. DADS encourages all providers to avoid situations that would result in a lapse in authorization dates requiring submission of a Purpose Code E (PC E).

DADS has no plans to eliminate the PC E. However, the agency encourages all providers to avoid situations that would result in a lapse in authorization dates requiring submission of a PC E.

Beginning Sept. 1, 2014, Star+Plus enrollment for acute care services is mandatory for people age 21 and older who

• have IDD,
• receive Medicaid, but not Medicare Part B, and
• live in an ICF/IID or receive waiver services through CLASS, DBMD, HCS or TxHmL.

Star+Plus enrollment for acute care services is voluntary for children and young adults (age 20 and younger) who

• have IDD,
• receive Medicaid, but not Medicare Part B,
• live in an ICF/IID or receive waiver services through CLASS, DBMD, HCS or TxHmL.

DADS regularly reviews its internal processes to increase efficiency. It is important to keep in mind, however, that the agency depends on providers to comply with submission standards to avoid authorization lapses. Providers are encouraged to engage in service planning to avoid authorization lapses.

DADS is not changing current IDD program processes related to ID/RC and IPC submission and review. Providers are encouraged to thoroughly check submissions to avoid the need for DADS to remand or request additional information or documentation from the provider to make an authorization determination. Providers are encouraged to make submissions to DADS as early as possible, within allotted timeframes, to allow for the potential need to request additional information or documentation. Upon request, DADS will continue to work with providers on specific, challenging cases to make authorization determinations and avoid authorization lapses.

CLASS and DBMD: When someone appeals a DADS adverse action, and that person has a right to service continuation, DADS enters a service authorization for the reduced service in the previously authorized amount. This lets the provider bill for services at the previously authorized amount during the appeal period. When a request for a new service is denied, the person does not have the right to access that service during the period before the outcome of the appeal.

HCS and TxHmL: DADS does not change the IPC in the CARE system until HHSC has notified the agency of its fair hearing decision.

It has been indicated that any lapse in ID/RC or IPC authorization may result in loss of a person’s Star+Plus acute care eligibility. Can an ID/RC or IPC authorization lapse for a short time without affecting Star+Plus acute care eligibility? Any lapse in ID/RC or IPC authorization could affect someone's Star+Plus acute care eligibility, regardless of the length of the lapse.

When a person needs rehabilitative therapy, such as following a surgery, the skilled therapy service must be accessed under Medicaid as an acute care service.

The IDD programs provide skilled therapies to people for longer term needs &mdash reduction of spasticity, maintenance of range of motion or communication skill training &mdash beyond what acute care Medicaid provides.

When proposing an IPC to DADS that includes a skilled therapy, the LTSS IDD provider may contact the individual’s assigned MCO's SC to request a copy of the MCO's denial, reduction or termination for an acute care service to demonstrate that non-waiver resources were pursued.

This expansion wont’ change PDN Medicaid benefits that a child may be eligible for. Children will continue to have access to this benefit up to age 21, at which time they must transition to an LTSS program as an adult.

Information Letter 14-41, Expansion of Medicaid Acute Care Services Provision of Day Activity and Health Services and Primary Home Care for Individuals in Intellectual and Development Disabilities Waivers (PDF), covers the provision of DAHS and PHC for people enrolled in the IDD waiver programs. The managed care transition scheduled for Sept. 1, 2014, is only for acute care services. People receiving Medicaid state plan DAHS, PCS or PHC services will continue to receive those services through the Medicaid fee-for-service model just as they do now. Services that are mutually exclusive will not change. Eligibility to receive state plan services while enrolled in a waiver program are not changing; PHC, HCS, CLASS and DBMD continue to be mutually exclusive. Only people enrolled in TxHmL may access PHC and TxHmL simultaneously. A Mutually Exclusive Services list is available online in PDF format.

This expansion does not change provider requirements for ID/RC and IPC development. Current contract review processes are also not changing. If ID/RC and IPC authorization lapses occur repeatedly for a particular provider contract, DADS Program Enrollment/Utilization Review (PE/UR) may make a referral to Community Services Contracts (CSC) and/or Waiver Survey and Certification (WS&C). CSC may place a vendor hold on the provider contract until the issue is resolved and/or WS&C may conduct an on-site visit with the provider to review the scope of the problem and, if necessary, cite the provider. If the problem continues and is not corrected, WS&C will recommend sanctions which may be upheld by the Sanctions Action Review Committee (SARC).

HCS and TxHmL providers may use CARE Screen C64 to review IPC expiration dates and CARE Screen C65 to review ID/RC expiration dates. Local authorities may use CARE Screen L64 to review IPC expiration dates and CARE Screen L65 to review ID/RC expiration dates. CARE user guides are available at:

• http://www2.mhmr.state.tx.us/655/cis/training/WaiverGuide.html and
• http://www2.mhmr.state.tx.us/655/cis/training/txhmlGuide.html

If a provider needs help accessing the CARE user guides, they may call the help desk at 512-438-4720.

The MCO will not directly access LOC and IPC information in CARE. Instead they will receive information regarding in which program (ICF/IID, CLASS, DBMD, HCS or TxHmL) an person is enrolled.

The Texas Administrative Code (40 TAC §9.166) requires that a person’s IPC be renewed at least annually, and before the IPC expires.

Section 9.166 also requires local authority SCs to notify the service planning team (SPT) at least 60, but no more than 90, calendar days before a person’s IPC expires that the person’s PDP must be reviewed and updated. Upon receiving this notification, the SPT must review and update the PDP and the LA service coordinator must send a copy of the updated PDP to the program provider within 10 calendar days of the PDP being updated.

DADS encourages providers to begin working on renewal documents as early as possible to ensure that they can complete data entry in CARE as far in advance as the system allows and submit required documentation to DADS early enough to avoid an authorization lapse. The CARE system allows a provider to enter a PC3 (renewal) ID/RC or a renewal IPC into CARE as early as 60 calendar days before the current ID/RC or IPC expiration date.

ICF/IID providers may use the Texas Medicaid and Healthcare Partnership (TMHP) Long-term Care (LTC) Online Portal to search for expiring ID/RCs.

The TMHP user guide (PDF) also may be accessed under the "Help" link located on the blue navigational bar in the TMHP LTC portal. Instructions for Form Status Inquiry (FSI) begin on page 16 of the guide. The provider selects the FSI link from the blue navigational bar, then selects " ID/RC 8578 Assessment" in the form type field, then enters a desired date range for their search to develop a report that can be exported into a Microsoft Excel spreadsheet. If the provider needs help with this feature, they may contact the TMHP helpdesk at 1-800-727-5436 or 1-800-626-4117.

• Acute care: Refers to basic health services, such as doctor visits, hospital, clinic or emergency room visits, medications
• Dual eligible: Refers to individuals receiving both Medicaid and Medicare benefits
• Financial Eligibility: Refers to the appropriate Medicaid coverage for the specific IDD program
• IDD Program(s): Refers to the ICF/IID, CLASS, DBMD, HCS, and TxHmL programs
• Provider (s): Refers to all contracted provider entity types:
  • CLASS CMAs and DSAs;
  • HCS and TxHmL program providers and LAs;
  • DBMD program providers; and
  • ICF/IID providers.

• CARE: Client Assignment and Registration system
• CLASS: Community Living Assistance and Support Services
• CMA: Case Management Agency
• CMS: Centers for Medicare & Medicaid (a federal agency)
• DADS: Texas Department of Aging and Disability Services
• DAHS: Day Activity and Health Services
• DBMD: Deaf Blind with Multiple Disabilities
• DSA: Direct Service Agency
• FC: Foster Care
• HCS: Home and Community-based Services
• HHSC: Texas Health and Human Services Commission
• ICF/IID: Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition
• ID/RC: Intellectual Developmental/Related Conditions form
• IDD: Intellectual and Developmental Disabilities
• IPC: Individual Plan of Care
• LA: Local Authority
• LOC: Level of Care
• LON: Level of Need
• LTC: Long-Term Care
• LTSS: Long-Term Services and Supports
• MCO: Managed Care Organization
• MEPD: Medicaid for the Elderly and Persons with Disabilities
• OT: Occupational Therapy
• PC: Purpose Code
• PCS/PHC: Primary Care Services/Primary Home Care
• PDN: Private Duty Nursing
• PDP: Person Directed Plan
• PT: Physical Therapy
• SC: Service Coordinator
• SPT: Service Planning Team
• SSA: Social Security Administration
• SSI: Supplemental Security Income
• Star+Plus: State of Texas Access Reform Plus
• TAC: Texas Administrative Code
• TIERS: Texas Integrated Eligibility Redesign System (HHSC's Medicaid eligibility system)
• TMHP: Texas Medicaid & Healthcare Partnership
• TxHmL: Texas Home Living
• WS&C: Waiver Survey and Certification
• UR: Utilization Review